Neurosurgery notes/CSF/Hydrocephalus (HCP)/Hydrocephalus and pregnancy

Hydrocephalus and pregnancy

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Hydrocephalus (HCP)

General

  • Patients with CSF shunts may become pregnant, and there are case reports of patients developing hydrocephalus during pregnancy requiring shunting.
  • With VP shunts, distal shunt problems may be higher in pregnancy. The following are management suggestions modified from Wisoffet al.

Preconception management of patients with shunts

  • Evaluation, including
    • Evaluation of shunt function
      • Preconception baseline MRI or CT. Further evaluation of shunt patency if any suspicion of malfunction.
      • Patients with slit ventricles may have reduced compliance and may become symptomatic with very small changes in volume
    • Assessment of medications, especially anticonvulsants
  • Counselling, including
    • Genetic counselling: if the HCP is due to a neural tube defect (NTD), then there is a 2–3% chance that the baby will have an NTD
    • Other recommendations include early administration of prenatal vitamins and avoiding teratogenic drugs and excessive heat (e.g. hot-tubs): Neural tube defects, Risk factors.

Gravid management

  • Close observation for signs of increased ICP
    • Headache, N/V, lethargy, ataxia, seizures…
      • Caution: these signs may mimic preeclampsia (which must also be ruled out).
    • 58% of patients exhibit signs of increased ICP, which may be due to
      • Decompensation of partial shunt malfunction
      • Shunt malfunction
      • Some show signs of increased ICP in spite of adequate shunt function, may be due to increased cerebral hydration and venous engorgement
      • Enlargement of tumour during pregnancy
      • Cerebral venous thrombosis: including dural sinus thrombosis & cortical venous thrombosis
      • Encephalopathy related to disordered autoregulation
  • Patients developing symptoms of increased ICP should have CT or MRI to compare ventricle size to preconception baseline study
    • If no change from preconception study, puncture shunt to measure ICP and culture CSF.
      • Consider radioisotope shunt-o-gram
    • If all studies are negative,
      • Then physiologic changes may be responsible.
      • Treatment
        • Bed rest,
        • Fluid restriction,
        • Steroids and/or diuretics (Severe cases).
      • If symptoms do not abate, then early delivery is recommended as soon as foetal lung maturity can be documented (give prophylactic antibiotics for 48 hrs before delivery)
    • If ventricles have enlarged and/or shunt malfunction is demonstrated on testing for shunt revision performed
      • In first two trimesters
        • VP shunt is preferred (do not use peritoneal trocar method after first trimester) and is tolerated well
      • In third trimester
        • VA or ventriculopleural shunt is used to avoid uterine trauma or induction of labour
  • Intrapartum management
    • Prophylactic antibiotics are recommended during labour and delivery to reduce the incidence of shunt infection.
      • Coliforms are the most common pathogen in L&D,
      • Ampicillin 2 g IV q 6 hrs, and
      • Gentamicin 1.5 mg/kg IV q 8 hrs in labour and× 48 hrs post partum
    • In patients without symptoms
      • A vaginal delivery is performed if obstetrically feasible (lower risk of forming adhesions or infection of distal shunt).
      • A shortened second stage is preferred since the increase in CSF pressure in this stage is probably greater than during other Valsalva manoeuvres
    • In the patient who becomes symptomatic near term or during labour
      • After stabilizing the patient a C-section under general anaesthesia (epidurals are contraindicated with elevated ICP) is performed with careful fluid monitoring and, in severe cases, steroids and diuretics